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11 Review / Derleme 1 Patellofemoral Arthrosis and Patellofemoral Arthroplasty Patellofemoral Artroz ve Patellofemoral Artroplasti Barış Yılmaz 1, Güzelali Özdemir 1, Baran Kömür 2, Serhat Mutlu 2, Bülent Yücel 2, Harun Mutlu 3 1 Clinic of Orthopedics and Traumatology, Fatih Sultan Mehmet Training and Research Hospital, İstanbul, Turkey 2 Clinic of Orthopedyics and Traumatology, Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey 3 Clinic of Orthopedics and Traumatology, G.O.P Taksim Training and Research Hospital, İstanbul, Turkey ABSTRACT The patellofemoral joint tends to develop osteoarthritis due to the high rates of anatomical abnormalities and exposure to large weights through relatively small areas. The rate of isolated patellofemoral arthrosis is 11% in men and 24% in women above 55 years of age. This gender difference may be due to the more frequent presence of patellar aligment problems and dysplasia in women. Although, patellofemoral arthrosis, in general, is treated by conservative methods, surgery should be considered for patients who have failed to benefit from weight loss, physical therapy and drug treatment because the disease leads to pain and loss of function. In the surgical treatment of patellofemoral arthrosis, methods such as arthroscopic debridement, management of loads that affect the patella, cartilage grafting, patellar resurfacing, patellafemoral arthroplasty (PFA), total joint replacement and patellectomy can be used. However, PFA has not been widely used. The reasons were problems with the initial design, and mistakes in patient selection, but those were reduced recently and this has led to increasing interest in the PFA. The current indications of PFA comprise of patients with little or no malalignment, and young patients with isolated patellofemoral disease who were planned for patellectomy due to symptom severity. Indeed, the outcomes from patients who were below 55 years of age with a 5-year follow up are promising. (JAREM 2014; 1: 1-3) Key Words: Patellafemoral joint, arthrosis, patellofemoral arthroplasty ÖZET Patellofemoral eklem büyük yüklerin dar temas alanları üzerinden etki etmesi ve nispeten anatomik anomali oranının sıklığı nedeniyle osteoartrite oldukça meyilli bir eklemdir. Tek başına patellofemoral artroz varlığı 55 yaş üstü erkeklerde %11, kadınlarda %24 oranında görülmekle birlikte bu cinsiyet farklılığının nedeni kadınlarda daha sık olan patellar dizilim bozukluğu ve displazi olabilir. Patellofemoral artroz genellikle konservatif yöntemler ile tedavi edilmeye çalışılsa da; tek başına ağrı ve fonksiyon kaybı yaratması nedeniyle kilo verme, fizik tedavi ve ilaç tedavisinden fayda görmeyen hastalar için cerrahi seçenekler gözönünde bulundurulmalıdır. Patellofemoral artroz cerrahi tedavisinde artroskopik debridman, patellayı etkileyen yüklerin düzenlenmesi, kıkırdak greftlemeleri, patellar yüzey yenilemeleri, Patellofemoral artroplasti (PFA), total eklem replasmanı ve patellektomiye uzanan yöntemler uygulanabilmektedir. Bununla birlikte PFA çok yaygın kullanım alanı bulamamıştır. Bunun nedeni olarak gösterilen ilk tasarımlardaki sorunlar ve hasta seçimindeki hata oranlarının azaltılması ile özellikle son yıllarda PFA ye olan ilgi de artmıştır. PFA nin günümüzdeki endikasyonları arasında yanlış dizilimin çok az olduğu ya da hiç olmadığı hastalar ve semptomların ciddiyeti nedeniyle patellektomi planlanan izole patellofemoral hastalığı olan genç hastalar vardır. Gerçekten de 55 yaş altı ve en az 5 yıllık takibi olan hastaların sonuçları cesaret vericidir. (JAREM 2014; 1: 1-3) Anahtar Sözcükler: Patellofemoral eklem, artroz, patellofemoral artroplasti INTRODUCTION The patellofemoral joint is a part of the knee and is located between the femoral condyles and patella. This joint is affected by various loads at different flexion angles. When the knee is fully extended, load on the patellofemoral joint is minimal, whereas the load becomes at the largest level at 60 to 90 flexion (1). In other words, at 10 knee flexion, the load on the patellofemoral joint equals to half the body weight, whereas it may be 3.5-fold body weight at 60 knee flexion. During difficult activities such as ascending or descending the stairs, the load on the patellofemoral joint may be 8 times the body weight (2). Between 0 to 30 flexion, dynamic stability of the patellofemoral joint is achieved by musculus vastus medialis obliqus, whereas static stability is achieved by the medial patellofemoral ligament. At further degrees of flexion movements, stability is achieved by bony structures following patellar sliding into the trochlear sulcus (3). However, the patellofemoral joint is actually accepted as the joint of extensor muscles since this joint lengthens the force arm of the quadriceps femoris muscle and changes the direction of muscle force. Thus, it plays an important role in knee stability. Therefore, patellofemoral joint problems may be considered as the problems of the knee extensor mechanism (4, 5). Complaints arising from the patellofemoral joint occur during movements against gravity. The primary complaint is pain behind the patella, medial to the joint, and sometimes at the popliteal fossa. This kind of pain intensifies during activities such as ascending the stairs, sitting with knees at flexion, and squatting (6, 7). At times, pain can be bilateral and, in general, it is not related to any trauma. Among the other complaints, patients frequently report sounds from the patellofemoral joint, feeling of uncoil or instability, and locking. These symptoms stem from impairment of the normal rhythmic movement of the patellofemoral joint (8, 9). Sensation of friction may be prominent, especially when the load on the patellofemoral joint is increased during ascending stairs and, rarely, it may be heard. Most of the patients with patellofemoral joint disease show effusion of the knee joint. Quadriceps atrophy may be seen in chronic cases. Diagnosis should be based on at least anteroposterior and lateral x-ray radiography of knee. Tunnel and tangential patella Address for Correspondence / Yazışma Adresi: Dr. Harun Mutlu, Clinic of Orthopedics and Traumatology, Taksim Training and Research Hospital, İstanbul, Turkey Phone: Received / Geliş Tarihi: Accepted / Kabul Tarihi: Telif Hakkı 2014 AVES Yayıncılık Ltd. Şti. Makale metnine web sayfasından ulaşılabilir. Copyright 2014 by AVES Yayıncılık Ltd. Available on-line at DOI: /jarem

12 2 Yılmaz et al. Patellofemoral Arthrosis. JAREM 2014; 1: 1-3 radiographies may frequently be added. Tangential patella radiography mostly involved Merchant and Mountain techniques in the literature. These radiographies show the patellofemoral joint. Although they are not routine, oblique radiographies may be necessary. Computerized tomography (CT) imaging of the patellofemoral joint enables evaluation of the patella and femoral condyle contours. CT arthrography may show retropatellar and trochlear articular cartilage and synovial surfaces. Magnetic resonance imaging (MRI) may be preferred in the diagnosis of patellofemoral joint diseases, as it is non-invasive and enables evaluation of bone, cartilage and soft tissues. The imaging plane is not confined to the transverse plane as in CT. It may provide imaging in all planes and it does not involve ionizing radiation. When necessary, arthroscopy is one of the most important current diagnostic and interventional methods (10, 11). The patellofemoral joint tends to develop osteoarthritis due to high rates of anatomical abnormalities and exposure to large weights through relatively small areas. Lateral patellofemoral joint involvement frequently accompanies lateral and medial femorotibial joint osteoarthritis. However, patellofemoral joint involvement may be isolated. Involvement of the medial patellofemoral joint is rare. The rate of isolated patellofemoral arthrosis is 11% in men and 24% in women above 55 years of age. This gender difference is due to the more frequent presence of patellar alignment problems and dysplasia in women (12, 13). Although conservative methods are preferred in the treatment of patellofemoral arthrosis, surgery should be considered for patients who fail to benefit from weight loss, physical therapy and drug treatment because the disease leads to pain and loss of function. In the surgical treatment of patellofemoral arthrosis, methods such as arthroscopic debridement, management of loads that affect the patella, cartilage grafting, patellar resurfacing, PFA, total joint replacement and patellectomy can be used (14). However, PFA has not been widely used. The reasons were problems with the initial design, and mistakes in patient selection, but those were reduced recently and this has led to increasing interest in PFA (15, 16). DISCUSSION The first report on patellofemoral arthroplasty was published by McKeever in 1955 which was an report of a successful prosthesis approach in patients with symptomatic isolated patellofemoral degenerative disease. Initial results showed that PFA was a good alternative to patellectomy and patellar skiving in the treatment of patellar osteoarthritis (17). In 1973, Levitt supported those results in his study and suggested that patellar resurfacing is a good alternative in the treatment of patellofemoral osteoarthritis. Subsequently, 39 of 45 patients reported that they were pleased with the McKeever prosthesis during 22 year follow up. In 1979, Blazina et al. (18) published the first report of patellar resurfacing and gave rise to PFA applications in the literature. Later studies reported a success rate of 44% to 90% for PFA. However, a 50% failure in 76 knees with a Lubinus prosthesis in 8 years was reported (19) and the main reasons for this failure were reported to be malalignment, wear and tear, repeated traumas and disease progression. New designs with shallow and wide femoral rims that enabled better fixation of the trochlea during flexion were developed. In addition, these designs allowed total replacement when the disease progressed (20, 21). Among the features of the new products, intramedullary instrumentation, wider size choices, minimal incision technique, longer cement and polyethylene forms, trochlear rims with superolateral extension which increase patellar clutch and trachlear angle that may reduce patellar prosthesis application problems can be listed. The purpose is to achieve success rates close to total knee prosthesis with normal knee kinematics. Results from the literature demonstrate that these sophisticated designs eliminate wrong alignment and early abrasion. Low complication rates and excellent range of motion were reported. Disease progression in the tibiofemoral joint is a problem that remains to be solved. These types of new design prostheses present an alternative treatment for total joint replacement in patients with isolated patellofemoral disease (Figure 1, 2) (22, 23). The current indications of PFA are patients without alignment problems and young patients who have severe symptoms and are planned for patellectomy due to isolated patellofemoral disease. An important advantage of this treatment is that meniscus and cruciate ligaments and thus the natural structure of the knee joint are preserved. The outcomes of a -5 year follow up in patients below 55 years of age are promising. In this group, the underlying reason is mostly the secondary osteoarthritis. Osteoarthritis results from isolated traumas such as patellar fracture, thus other parts of the knee are not affected, and disease progression in the tibiofemoral joint is slower (23, 24). Philippe H. and Caton J. of France reported the results of 70 PFA with a 10-year follow up and they observed no complication of arthroplasty and 3 of 5 patients underwent revision surgery due to progression of tibiofemoral joint disease. Four patients had Figure 1. Full thickness cartilage defect of the patella A B Figure 2. Postoperative AP and lateral view following patellar resurfacing

18 8 Güler et al. Winograd Surgical Method for Ingrown Toenils. JAREM 2014; 1: 7-11 of the surrounding soft tissues. Finally, the nail substance enters the nail groove and causes infection (5-10). Although there are many conservative and surgical treatments for ingrown toenails, the optimum treatment method has not been clearly defined because of the high recurrence rates, low degrees of patient satisfaction, and reported cosmetic issues. In this study, we evaluated the partial matrix excision treatment for the unilateral ingrown hallux toenail. METHODS Partial matrix excision was performed on 239 patients (127 males, 112 females, mean age: 37.4 years, age range: years) who had a unilateral ingrown toenail from December 2008-October Fully informed consent was obtained from all patients. The ethics committee approved our study. Patients with onychomycosis were excluded from study after a dermatology consultation. Also, patients who had prior surgical treatment or bilateral or recurrent ingrown toenails and those who healed with conservative treatment were excluded. Radiography was not performed routinely. Major complaints included hallux pain, a foul-smelling discharge, and difficulty walking. Etiologies included inappropriate nail trimming (118 patients), narrow, tight footwear (28 patients), recurrent trauma (17 patients), and poor foot care (76 patients). Patients were classified according to Heifetz s ingrown toenail classification system (11). This system classifies ingrowing toenails into the following three Stages: 1) Stage l: mild swelling, erythema, and tenderness along the lateral nail fold (inflammatory Stage), 2) Stage ll: infection with active pus that was dependent on a bulged nail fold over the lateral nail plate edge (abscess Stage), and 3) Stage lll: inhibition of free drainage by granulation tissue on the lateral nail fold (granulation Stage). During the first evaluation, 62 patients were classified as Stage l, 96 as Stage ll, and 81 as Stage lll. Infection-related active drainage was evident in 178 (74%) patients. Prior to treatment with surgery, Stage I and II patients were advised to wear shoes with a wide and open forefoot box and to utilize warm foot baths. Silver nitrate was applied to the Stage III patients ingrown toenails. In addition to the aforementioned conservative treatments, an oral, systemic, first-generation cephalosporin (cephalexin, 1 gr/day in two doses) was prescribed to patients with infections before the surgical procedure. Bacteriological and fungal examinations were not performed. Surgical treatment was indicated for patients who did not benefit from conservative treatment. Surgical Technique The surgical procedure was performed on 239 patients after administration of digital anesthesia using 20 mg/ml prilocaine HCl and with use of a digital tourniquet. A colored (different from skin) tourniquet was used or a clamp was fixed to the tourniquet for identification (Figure 1). Winograd s partial matrix excision procedure was performed on all patients. A vertical incision was made through the nail plate on the ingrown side with a 15 blade. The incision included the length of the nail bed up to 4-5 mm proximal to the nail-skin border. The proximal aspect of the nail bed was excised with an oblique incision. Hypertrophied soft tissue covering the nail groove was excised through to the nail bed margin (Figure 2). Care was taken to prevent interphalangeal articulation and extensor tendon damage. All white-colored germinal matrix located near the nail fold was excised. The matrix on the distal phalanx cortex was curetted, and polypropylene sutures were placed in the skin edges (Figure 3). A pressurized dressing was applied, and the foot was elevated. Patients were prescribed non-steroidal antiinflammatory drugs and antibiotics (cephalexin 1 gr/day in two doses). The dressings were changed every 2 days, and the sutures were removed after 2 weeks. Patients were evaluated at 6-month Figure 1. Preoperative preparation Figure 2. Winograd s partial matrix excision procedure Figure 3. Postoperative appearance

19 Güler et al. Winograd Surgical Method for Ingrown Toenils. JAREM 2014; 1: intervals. Time periods until return to daily living, return to work, and recurrence were recorded. Patients were asked if they would undergo the same surgical procedure it they had another ingrown toenail and were also were asked about their overall satisfaction and if they had any cosmetic issues. The mean follow-up time was 27 months (range: months). RESULTS There were no reports of neurological or vascular complications, nor any deep tissue infections or osteomyelitis. Recurrence occurred in 3.7% of patients (four females, five males). The mean recurrence time was 5.6 months (range: 2-9 months). Of those cases of recurrence, three were Stage l, five were Stage ll, and six were Stage lll. Revision surgery was performed for recurrent cases, and after an average of 14 months, no cases of recurrence were reported. Patients without recurrence returned their daily activities without any symptoms. The mean times until returning to daily living and work were 11.3 days (range: days) and 8.7 days (range 6-13 days), respectively. A total of 230 patients (96.3%) were satisfied with the procedure. Each of the nine patients who were not satisfied had experienced recurrence and undergone revision surgery. The majority of patients (231; 966%) was satisfied with the cosmetic results. Of the eight patients who were not, six had revision surgery after recurrence. All patients had complaints of a narrowed nail. DISCUSSION Ingrown toenail is common nail pathology. The hallux is most commonly affected toe. It is believed that both habitual and anatomical factors are involved in the etiology of ingrown toenail. While a congenital, thick nail substance is a predisposing anatomical factor, improper nail trimming, tight footwear, recurrent trauma, poor foot care, and hyperhidrosis are also involved in ingrown toenail development (12, 13). In our study, 118 patients exercised inappropriate nail trimming; 28 wore narrow, tight footwear; 17 had a history of recurrent trauma; and 76 patients practiced improper foot care. Several theories have been suggested regarding ingrown toenail etiology involving the nail itself or the soft tissue surrounding the nail (14-16). The patient experiences pain and swelling and may notice granulation tissue, depending on the penetration of the nail rim into the soft tissues (17). That penetration causes an inflammatory response and frequently results in the formation of bulge at the nail rim (18). Contrarily, the wider medial and lateral soft tissue of the hallux may cause the pathology instead of the nail. According to this theory, the wider load creates pressure, which in turn causes necrosis and inflammation that induce the ingrown toenail (16, 19). Pearson et al. (20) reported no nail abnormalities in symptomatic patients with ingrown toenails in a prospective study. They concluded that treatment should not be related to nail abnormalities. However, others believe nail abnormalities to be the primary factor in ingrown toenails, and controversy remains regarding whether nail abnormalities or ingrown nail folds are the cause. Ingrown toenail may also result from osseous malformation of the dorsal surface of the distal phalanx or rough thickening of the nail as a consequence of a fungal infection of the nail bed. Trauma, paronychia, onycholysis, and fungal infections should be considered differential diagnoses in ingrown toenails and thoroughly investigated. In our study, any patients with a suspicion of nail malformation or fungal infection were evaluated by a dermatologist and excluded. In these cases, maintaining focus on the possible predisposing factors is suggested. There are various conservative and surgical treatments for ingrown toenail (21, 22). Although the effectiveness of conservative treatments, such as footwear with an open and wide toe, warm foot baths, bandaging, administration of antibiotics, the use of the corrugated splint technique, or cotton seton, has not yet been demonstrated, these treatments continue to be suggested as the standard of care for mild and moderate ingrown toenail cases (5, 21, 22). For our Stage l and ll patients, footwear with an open and wide toe, warm footbaths, and antibiotics were used prior to surgery. Silver nitrate was applied to Stage III patients. Surgical treatment was performed in patients who did not benefit from conservative treatment. Surgery can easily be performed under local anesthesia. A digital tourniquet made from a surgical glove should be applied. At the end of the surgery, the tourniquet must be removed and not be forgotten, as this could cause serious complications (5). To prevent this oversight, we suggest using a different colored surgical glove or attaching a clamp as a reminder. In our study, we used both blue surgical gloves and a clamp. Surgical techniques may incorporate the following: 1) partial nail substance excision, 2) nail bed and nail matrix partial excision, 3) nail matrix chemical ablation, 4) soft tissue excision with nail bed and nail matrix treatment, or 4) only soft tissue excision (11, 22). Resection and ablation techniques aim at the germinal matrix, which provides nail growth, thereby preventing regeneration of the nail. However, this method can cause cosmetic issues, depending on the level of matricectomy. Also, new nail spicules can form, and recurrence is possible if matricectomy is performed inadequately (11, 22). Partial nail substance excision is performed on unilateral Stages l and ll ingrown toenails without granulation tissue. After this procedure, patients quickly return to their daily activities and wear wide casual shoes. However, the recurrence rate of this procedure can reach 70% (22). In 1936, Winograd determined that both the nail bed and nail matrix curettage should be used in ingrown toenail treatment (11). This method is a relatively easy and standardized surgical technique. The advantage of this technique is that no specialized chemicals or surgical equipment is needed. However, Kose et al. (23) reported that patients who had partial matrix excision with Winograd s technique complained of a narrowed nail substance with a proximal incision scar. Isik et al. (24) compared the partial matrix excision with a combined treatment (partial matrix excisionphenol application). Although no significant differences in duration of time to return to daily activities, postoperative pain, or recurrence rate were detected, the treatment cost and surgical

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